Saturday, February 6, 2016

Med School Memories

The first year of Medical School was a jumble of lectures and labs punctuated with brief encounters with actual live patients.
 There was the half day at one of the local Emergency Rooms where I was joined by a fourth year student. I'd been in med school for about three weeks. I had become well versed in the anatomy of the back muscles and the histology of the liver and spleen, but I knew nothing of authentic diseases or their treatment.
We met one of the ER Attendings, an Internist, and I was treated to a few hour of medical heiroglyphics. We were quizzed on the therapy for urinary tract infections, a pretty simple question. As I began to answer, the fourth year spouted off a litany of different antibiotic choices, drowning out my suggestion of Penicillin. At that time in my medical career I thought penicillin was the antibiotic and was effective treatment for any and all infections. This may have been true in 1945. But, it was now 1980 and the list of antibiotics was growing longer everyday. I stayed quiet for the final few hours, listening and learning rather than demonstrating my ignorance.

My next encounter with real patients was a four week elective in Urology, myself along with two of my classmates. Our instructor was Dr. Leake. We also had two sessions with Dr. Cockett. Leake and Cockett. Can you think of two more appropriate names for Urologists? One of the highlights of these four weeks was visiting Mr. Godfrey.
Poor Mr. Godfrey had cancer of the prostate and was receiving combined Radiation and hormonal therapy. We saw him twice a week and each time Dr. Leake wanted us to do a rectal exam on the unfortunate  Mr. Godfrey. Without even a sigh Mr.Godfrey turned on his side and suffered through this biweekly ritual. The last session of this elective finally came which meant the last four rectal exams Mr. Godfrey would have to endure. We all arrived sporting those big "We're Number One" gloves frequently seen at sporting events.
“OK, Mr. Godfrey, time for your rectal exams.” We chimed in unison.
 Dr. Leake was not amused, but our patient had a nice chuckle.
There were no other memorable clinical encounters until the third year. The entire class eagerly began “General Clerkship.” Four weeks were allotted to teach us how to talk to, listen to and touch the, up until now, sacred creature called, “The Patient.”
We were told to let the patient talk, to listen actively and guide the patient down the history road so that they would impart as much information as possible. We were taught how to guide a rambling patient back to the clinical road which lead to the formulation of the all important “Differential Diagnosis.” Thus, it was emphasized over and over, the history would guide the next steps of a patient’s evaluation.
We discussed the philosophical and practical concerns along with the grave responsibility that accompanied the “Laying on of Hands.” The actual physical exam meant bursting through societal taboo’s against penetrating another individual’s personal space, sometimes invading their most personal and intimate parts, always towards the goal of healing.
“Just the act of physical touching may be beneficial to your patient’s wellbeing,” one psychiatrist lectured.
We were treated to Dr. L demonstrating a complete physical exam (except rectal and pelvic) on one of our classmates. He spent about forty five minutes observing, palpating and auscultating, in the end declaring:
As you can see, this complete physical need not be an all day affair.”
In our more modern times, when a primary care physician may see 50-60 patients a day, performiong a forty five minute exam on each patient would make for a very long day indeed.
We all waited with fear and trepidation for the “Pelvic Day.” This was the day when each student would receive indoctrination into the intricacies of the female pelvic exam. Professional models were hired, each set up in a private cubicle where the student was given about ten minutes of monitored probing.
“My uterus is retroflexed,” my model reported, “so you would need to do a rectal exam to properly feel it. You should be able to feel each ovary however.”
“Until you’ve done about two hundred pelvic exams you may as well be waving your fingers in the wind,” Dr. A, one of our instructors, commented.
Finally, the last pieces of the physical exam came up: the aforementioned rectal exam and the male genital exam. These we did on each other.
“Never go to a Proctologist who can palm a basketball,” one instructor joked.
“You should be concerned if you feel both your examiners hands on your shoulders during a rectal exam,” another quipped.
“All in good fun to lighten the tension,” they said.
Maybe they should have volunteered to be subjects… all in the name of education, of course.
Finally, we were finished with general clerkship and were ready to be set loose upon the unsuspecting patients of Rochester, New York.
“Go do an H&P on the new admission in 612, a Gertie Black, CHF,” my third year resident ordered.
Ready or not here I come, Ms. Black
I perused the chart of patient Black before venturing into see her. I glanced across the nurse’s station into her room and caught a glimpse of my new patient. She was about five feet tall and five feet wide. At the precise moment I looked over at her she bent over. Her hospital gown did little to cover her ample assets and I was treated to a “full moon over Rochester.” So went my introduction to clinical medicine at Strong Memorial Hospital in Rochester, New York.
It wasn’t long before I was churning out 10-15 page H&P’s on a daily basis. The history part, the H, was not a problem. Ask the right question and listen. My patients had no qualms about opening up to me, revealing the darkest secrets of their lives.
“I… like… to smoke… a few… joints… every day… well… several… times… a day,” Mr. M. confided. He had been doing this for most of his seventy years. His very measured, deliberate speech no longer was a surprise.
“I prefer women’s underwear,” another man confided. “It’s more comfortable.”
“I put my cat in the drying machine when I was seven,” an elderly woman reported. I really didn’t think it was relevant to her having hemorrhoids, but one never knows.
“I drink a little every day, maybe three beers a day, and a couple of glasses of wine, and I have two martinis after dinner and a brandy at bedtime,” a councilman confessed.
And so it went.
The intricacies of the physical exam, the P, were more of a challenge.
As a class we shared our interesting heart murmurs, palpable lumps and bumps, hernias, rales, rhonchi and wheezes. Gradually, I thought I was developing some physical exam proficiency.
Then came my day. I was chosen to present to Dr. M on rounds. My patient was Cora, sixty years old, with COPD and Congestive Heart Failure, admitted with shortness of breath.
I questioned her every way I could, going back to her childhood days, looking for any every possible contributing factor to her severe COPD. I tried to anticipate any and all questions.
I examined her from top to bottom and then bottom to top. She had a barrel chest, an S3, mild JVD, expiratory wheezing and, I decided, a right ventricular heave.
I wasn’t really sure about the right ventricular heave. A definition follows:

“When there is pulmonary hypertension, the Right ventricle has to overwork, it has to pump against the increased pressure in the lungs. So if the heel of the hand is placed immediately lateral to the LEFT sternal border, one can feel the right ventricle being pushed anteriorly. The heel of the hand is lifted off the chest wall with each systole, and this is the heave.”

 I’m still not sure if I felt anything. But, I read it was associated with severe COPD and poor Cora certainly qualified. I convinced myself it was present. And, this was my chance to impress the Attending staff.
My moment came.
“Cora is a sixty year old female who was admitted to the hospital complaining of shortness of breath…two packs of cigarettes a day for forty years…distant breath sounds bilaterally…right ventricular heave…being evaluated for lung transplant.”
Silence.
I’ve done it. There speechless. I’m sure they’ve never been so dazzled by a med student.
“Dr. Gelber,” Dr. M began, “could you demonstrate how one examines a patient and determines the presence of a right ventricular heave?”
Wait, I know this.
“Good morning, again, Cora,” I greeted her as  I moved to her bedside. “I need to check your chest.”
“Whatever you need to do, Dr. G,” she turned to Dr. M. “Dr. G’s a good doctor. He spent an hour with me yesterday, just listening and checking me. It’s OK, go ahead and do what needs to be done.”
I put my hand alongside her sternum. Unfortunately, I put it on the right side and felt nothing.
“I’m not sure it’s there,” I murmured softly.
“It would probably help if you put your hand in the proper spot,” Dr. M. observed.
“Oh, yeah,” I stammered, even more softly.
I moved my hand to the proper spot and still felt nothing.
Dr. M. moved in. he put his hand along the left sternal border, watched her breathing and then turned to our group.
“Definitely no right ventricular heave,” he announced. “Maybe, Dr. Gelber, you should be a surgeon.”
A seed was sown.